DOI: 10.1097/01.prs.0000254359.67202.7e

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Issn Print: 0032-1052

Publication Date: 2007/04/01


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Discussion

Steven J. Kronowitz

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Freire and colleagues prospectively evaluated pain in the lower back, shoulders, and neck and functional capacity in women with symptomatic mammary hypertrophy before and after reduction mammaplasty. A unique practice opportunity allowed for them to equally distribute 100 patients with symptomatic mammary hypertrophy to either undergo reduction mammaplasty immediately or be placed on a waiting list and scheduled for reduction mammaplasty 6 months later. Outcome measures were concentrated on activities of daily living, including getting up, getting dressed, walking, taking a shower, reaching for and grasping objects, and performing domestic tasks. Even though Netscher et al.1 found that weight loss alone cannot generally be regarded as the sole treatment for symptomatic mammary hypertrophy, patients with a body mass index of greater than 30 kg/m2 were excluded from participation in this study to eliminate obesity as a potential causative factor.
Important findings of this study included the complete absence of postoperative pain in all three regions (lower back, neck, and shoulders) in 48 percent of patients who reported symptoms before reduction mammaplasty. The remaining 52 percent of the patients obtained significant (p < 0.001) pain relief in one or more of the evaluated anatomical regions. In addition, compared with the control group (patients put on a waiting list for reduction mammaplasty), patients who underwent reduction mammaplasty had significant improvement in their ability to perform activities of daily living that most individuals would consider imperative to obtain and retain employment and care for a family. Another important finding was that there was no statistical correlation between the amount of breast tissue resected and significant improvement in pain or functional capacity. Despite the significant benefits that the affected patients in this study obtained with reduction mammaplasty, many of the patients in this study might not have qualified for insurance coverage for the procedure in the United States because of inadequate weight of the resected breast tissue (the mean weight in this study was approximately 520 g per breast).
Although symptomatic mammary hypertrophy has been shown to be correctable with reduction mammaplasty, many health insurance companies have made it difficult for patients to obtain coverage for this procedure, classifying it as cosmetic. Currently, many insurance companies determine coverage for reduction mammaplasty solely on the basis of the weight of the resected breast tissue, which this study shows has no correlation with symptoms. The results of this study and others1,2 indicate that to most appropriately identify patients who will benefit from reduction mammaplasty, insurance companies should base reimbursement considerations on a multifactorial assessment scale including an evaluation of the patient’s functional capacity. Although many insurance companies may consider this approach subjective, it may ultimately reduce overall costs for other related health care issues. A prior study by Freire et al.3 showed that patients with symptomatic mammary hypertrophy who undergo reduction mammaplasty are more physically active, which may lead to improved overall health. In addition, Sood et al.4 found that reduction mammaplasty reduces patients’ complaints of shortness of breath and correlates with improved results on pulmonary function tests. Furthermore, Blomqvist and Brandberg5 showed evidence that the quality-of-life benefits from reduction mammaplasty are long term.
As plastic surgeons, we should pursue further scientific studies (e.g., with electromyography and positron emission tomography) to obtain additional documentation to justify the need for insurance reimbursement for women suffering from mammary hypertrophy. Future studies might include an evaluation of the potential impact of breast ptosis, the breast parenchymal changes that tend to occur after childbearing, and the composition of the breast tissue (fibroglandular or adipose) on presenting symptoms.
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